Surgeons weigh in on risks of obesity surgery

The operation saved Joel Sopp’s life, but not before almost killing him.

The day after surgeons stapled Sopp’s stomach down to the size of a plum during surgery to fight obesity, doctors discovered he was bleeding internally and his kidneys were shutting down. He spent 19 days in hospital and 20 hours on dialysis for what was originally meant to be an “in-Monday-morning, home-by-Wednesday night” procedure.

Yet Sopp, of Shaunavon, Sask., has no regrets. His weight had topped out at 440 pounds before his surgery in June 2009; today, he weighs 250 pounds. He’s grateful that his surgeon caught the complications early and acted quickly. Still, “I don’t want bariatric surgery to be someone’s first choice. I want it to be their last-ditch effort,” Sopp says. “This isn’t an easy surgery.”

Post-operative hemorrhage. Leaking from staples in the stomach. Bowel “misconstruction.” As the surgical treatment of obesity grows in Canada, doctors are being warned of the uncommon but potentially catastrophic complications that can occur.

In a recent review of 21 closed malpractice cases relating to bariatric surgery between 2006 and 2011, the Canadian Medical Protective Association — the group that provides liability insurance to the nation’s doctors — found problems ranging from failing to discuss the risks of surgery with the patient to death from septic shock. The patients’ body mass indexes (BMI) ranged from 35 to 74.

In the October edition of the Canadian Journal of Surgery, a University of Alberta team reviews “rare but potentially devastating” complications that can arise from laparoscopic Roux-en-Y, major abdominal surgery that involves essentially building a new stomach.

The back-to-back reports come as surgeons discuss lowering the minimum BMI required to qualify for obesity surgery, a move that could make more people candidates for an anatomy-reconfiguring operation once reserved for the most drastic cases.

Currently, a BMI of 40 or more is needed to qualify for bariatric surgery, or a BMI of 35 with one or more serious underlying conditions, such as diabetes or high blood pressure.

But as the provinces look at expanding access to surgery, discussions are underway in the bariatric surgery community worldwide to lower the qualifying BMI to 32 for people with serious “co-morbidities,” notably diabetes. Studies are showing that gastric bypass surgery can put Type 2 diabetes into complete remission.

“After a gastric bypass upwards of 70 to 80 per cent of patients have complete resolution of their Type 2 diabetes,” says Dr. Shahzeer Karmali, an assistant professor of surgery at the U of Alberta and a co-author of the review article on complications associated with Roux-en-Y.

Other studies have found gastric bypass decreases the incidence of hypertension, high cholesterol levels and obstructive sleep apnea.

But some experts worry that not enough long-term data exist to support lowering the criteria for obesity surgery. While the overall risk of serious complications is low, stomach-restricting surgery is “serious, complicated surgery involving complex and difficult patients,” says Dr. Arya Sharma, medical director of the Alberta Health Services provincial obesity program.

“We don’t even have the capacity to treat the one million Canadians who meet the current criteria — why would anyone want to expand these?”

Sharma says there isn’t adequate long-term follow-up care of patients undergoing surgery now. “Before you go out and offer this to patients with BMIs of 32 or 30, you better make sure you have a system in place that looks after these patients in the long term before you start thinking about, ‘Who else can we operate on?’ ”

A total of 2,385 bariatric procedures were performed in Canadian hospitals in 2008-09, a near doubling over 2004-05 numbers, according to a study published in Healthcare Quarterly. But Canadians are also getting surgery in private clinics as well as outside of the country. Ontario alone is expected to fund more than 2,000 gastric bypass surgeries in 2013. In Alberta, “We hope this year to be doing somewhere between six (hundred) and seven hundred bariatric surgical cases,” said Dr. Daniel Birch, medical director of the Centre for the Advancement of Minimally Invasive Surgery at Edmonton’s Royal Alexandra Hospital.

Laparoscopic Roux-en-Y gastric bypass is considered the “gold-standard” surgery for extreme obesity against which all others are compared, the Alberta team writes in the Canadian Journal of Surgery. With Roux-en-Y, a small portion of the upper stomach is stapled or stitched closed to create a small pouch for food that bypasses a large portion of the stomach. People feel fuller, faster.

Unlike gastric banding, where a saline-filled band is looped around the upper part of the stomach, restricting how much people can eat at one time, Roux-en-Y permanently rearranges the digestive tract. Gastric banding, by contrast, is entirely reversible, but studies suggest Roux-en-Y results in greater weight loss. Today, it is the most frequently performed weight loss surgery worldwide. According to Montreal bariatric surgeon Dr. Nicolas Christou, a professor of surgery at McGill University, the overall risk of death from Roux-en-Y “is equal to having your gallbladder removed.”

“If your (mortality rate) is above 0.5 per cent, you should stop doing this procedure,” Christou says. For the severely obese, gastric bypass can be life-saving, he added. It’s not uncommon for patients to lose 100 pounds or more. Writing in the Canadian Journal of Surgery, Karmali’s team said laparoscopic Roux-en-Y “offers excellent long-term results.”

Still, Christou says he is aware of complications and deaths “that should not have happened had the team had proper training.”

Two complications feared most are staple-line leaks and small-bowel obstructions that result when loops of bowel become strangled or trapped by internal hernias — a “worrisome complication” that can be difficult to diagnose, Birch said. The small bowel can be irreversibly damaged and need to be removed.

Staple-line leaks occur when the connections between the “new” stomach and intestines weaken or break, leaking bowel fluid into the abdominal cavity. That can cause inflammation and potentially life-threatening bacterial infections. “One of the critical things we look for in the first day or two (after surgery) is elevated heart rate,” Birch said. “That’s a very sensitive indicator that the patient may have something, such as bleeding or leaking, going on.”

The risks of bariatric surgery are lower when performed in specialized high-volume centres of excellence, said Dr. Mehran Anvari, president of the Canadian Association of Bariatric Physicians and Surgeons.

“Go ahead and aim for a better you in 2013, however you see fit. But, whether you shrink, swell or stagnate, why not make a secondary resolution? Never complain about your body aloud”, writes Reb Stevenson.